Healthcare Musings - September 2009

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3 Billion Here, 10 Billion There ... Pretty Soon You're Talking Real Money
by John Shagoury

The patient care benefits and technological capabilities of high-tech diagnostic medical imaging are proven. However, there are two major concerns in this current system - excessive radiation risks for young patients and skyrocketing costs related to medically unnecessary tests being ordered by physicians. To combat these issues, an alliance of leading healthcare providers, technology companies and diagnostic imaging organizations have joined forces to form the Imaging e-Ordering Coalition.  

The Imaging e-Ordering Coalition estimates that $3-$10 billion is wasted annually on unnecessary imaging procedures. In a time when healthcare reform is as close to happening as it’s ever been, wasted billions is something no one in the industry is proud of.

Members of the Coalition are devoting their energies to help educate policy makers and healthcare providers about a new way of assuring that all patients receive the most medically appropriate diagnostic imaging test for their specific condition. Electronic decision support (e-Ordering) is a patient-centered solution that provides physicians with the best possible clinical information at the time they are ordering a patient’s medical exam to ensure that the ordered exam is of high utility (medically appropriate), correlates to the high likelihood, or yield of a positive outcome (the exam will help in treatment) and that the exam synchs with the patient’s insurance plan to verify that the exam will be reimbursed.

Unknown to Many

It’s scary how billions can be spent in areas that are simply not necessary. Today, for example, if a patient goes to his or her doctor for knee pain, the doctor may be quick to order an MRI of the knee for a few reasons.

  1. The doctor thinks that it is truly the best exam to diagnose the injury.
  2. The doctor is practicing defensive medicine, worried if he/she doesn’t do an MRI and something serious is found later that they may be held accountable for malpractice.
  3. The office where the doctor treats patients owns an MRI machine and they are financially incented to use it (they bill more and are therefore paid more).

As patients, we assume doctors have our care plan as the top priority as they treat us, and while the majority of doctors do, patients also presume that doctors know all the answers. It’s a double-edged sword scenario. On one hand we want tests to diagnose our symptoms and potentially speed recovery, but on the other hand we don’t want inflated industry costs for unnecessary exams, wasted time, maxed-out personal deductibles, additional co-pays, missed days of work for testing, or increased exposure to cancer-causing radiation.

Insurers Try to Cut Costs, but What about Patient Care?

Currently, insurers are working to manage utilization to reduce reimbursement charges. In many cases, healthcare insurers hire radiology benefit managers (RBMs), which are organizations employed to manage utilization and costs associated with high-tech diagnostic imaging. With this workflow, physicians must receive approval before ordering an imaging service for a patient. Concerns with the RBM model include regulatory oversight and a manually burdensome “prior authorization” system.  In fact, patients are often denied the imaging studies their physicians believe are warranted, are steered toward imaging providers with less expensive contracted rates (and possibly older more inefficient equipment), or are forced to wait days or weeks to receive vital imaging services. This process is broken because the decision leaves the doctor’s office and is made by a third-party who is paid to reduce costs (volume) for ordered exams.

Keeping Care Decisions between the Physician and Patient

Recently, more than 2,300 Minnesota providers embarked on a year-long pilot program to use electronic decision support (e-Ordering) as part of the workflow process when ordering high-tech diagnostic imaging exams; this option was accepted by five participating health plans as an alternative to prior authorization. The results concluded that there were less exams ordered with e-Ordering and those that were ordered had an increase in diagnostic utility (medical appropriateness) versus orders made without it.

As part of the e-Ordering process, doctors have access to clinical data at the time care is being discussed with the patient. Ordering clinicians enter patient specific information along with the requested exam into the e-Ordering system and, based on the exam’s utility score, the system may provide alternative procedures that better suits the patient’s indications, age and sex. The physician can then select the recommended procedure, or override the system’s suggestion and move ahead with their originally requested exam.

e-Ordering benefits providers, health plans and patients alike. In addition to avoiding the expenses and inefficiency of RBM prior notification, providers have immediate information about the usefulness of the high-tech imaging test they want to order. The immediate feedback eliminates patient wait times for exam scheduling, reduces the risk of unnecessary radiation exposure, enhances patient-physician relationships through point-of-care decision making and expedites high-tech imaging so patients have the appropriate diagnostic study already completed before seeing a specialist.

The Imaging e-Ordering Coalition sees a day very soon when these decision support tools will assure medically appropriate imaging tests for all patients, nationwide.  It’s all about ensuring the right test at the right time.

The Imaging e-Ordering Coalition is represented by legal authority and lobbying firm Holland & Knight. For information on membership please call +1 (781) 565-4893. To date, the following organizations are members of the Imaging e-Ordering Coalition: American College of Radiology (ACR), Center for Diagnostic Imaging (CDI), GE Healthcare, Medicalis, Merge Healthcare and Nuance Communications, Inc.

About the Author
John Shagoury is the President of Nuance’s Healthcare business, which provides proven, speech-enabled clinical documentation and communication solutions. Nuance’s closed-loop radiology management solutions support the radiology practice from start to finish by providing radiology decision support to enable data driven (RadPort), real-time e-Ordering, speech recognition reporting (PowerScribe and RadWhere), critical test result management (Veriphy), and a business intelligence solution for utilization management, patient and outcomes analysis, as well as clinical and operational trending (RadCube). With more than 3,000 healthcare customers worldwide, Nuance has the experience and solutions that meet the individual needs of any size healthcare provider organization.

You can reach John Shagoury at john.shagoury@nuance.com or call 781-565-5000.
 

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